PNO-IV-99-024, on 990512,notified Ks Radiation Control Program of Event Whereby 28-yr Old Female Patient Apparently 20 Wks Pregnant,Was Administered Therapeutic Dose of 11.8 Mci of I-131 for Graves Disease.Licensee Contacted DOE
| ML20206L680 | |
| Person / Time | |
|---|---|
| Issue date: | 05/13/1999 |
| From: | Linda Howell, Mark Shaffer NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION IV) |
| To: | |
| References | |
| PNO-IV-99-024, PNO-IV-99-24, NUDOCS 9905140084 | |
| Download: ML20206L680 (1) | |
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, May 13,1999 PRELIMINARY NOTIFICATION OF EVENT OR UNUSUAL OCCURRENCE PNO-IV-99-024 This preliminary notification constitutes EARLY notice of events of POSSIBLE safety or public interest significance. The information is as initially received without verification or evaluation, and is basically all that is known by Region IV staff in Arlington, Texas on this date.
Facility Licensee Emeroency Classification State Of Kansas Notification of Unusual Event Via-Christi St. Francis Reg Med Ctr Alert Wichita, Kansas Site Area Emergency i
License No: 19-C030-01 General Emergency X Not Applicable
Subject:
MEDICAL MISADMINISTRATION INVOLVING IODINE-131 On May 12,1999, the radiation safety officer for Via-Christi Saint Francis Regional Medical Center, a State of Kansas licensee, notified the Kansas Radiation Control Program (KRCP) of an event whereby a 28-year-old female patient, apparently 20 weeks pregnant, was administered a therapeutic dose of 11.8 millicuries of lodine-131 for graves disease. The licensee contacted the Department of Energy Radiation Emergency Assistance Center / Training Site (REAC/TS) to request assistance with dosimetry calculations, and a representative of REACTTS agreed to act as a consultant to the patient's referring.
phys!cians conceming matemal and fetal clinical issues, as needed.
REAC/TS calculated that the fetus received a whole body dose of 3.0 centigray and a thyroid dose of 253 Gray. The fetal thyroid dose is expected to be ablative. The licensee is contacting the referring physicians, and KRCP expects that the licensee will notify the patient of the event as soon as possible. KRCP has initiated an investigation of this event.
At this time, it is unclear if or why the licensee failed to follow procedures for performing a pregnancy test o". the patient prior to administering the therapeutic dose, or how the -
pregnancy was verified. RIV received notification of this occurrence by the State of Kansas, through the NRC Operations Center, on May 12,1999.
Region IV has informed OSP and NMSS.
This information has been discussed with the State of Kansas and is current as of 11:30
+ a.m. (CDT) on May 13,1999.
Contact:
Mark R. Shaffer (817)860-8287 Linda L. Howell (817)860-8213 9905140084 990513 PDR ISE D W {. }Q. Ef PNO-IV-99-024 PDR
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